Not All the News on Bariatric Surgery Is Good

PITTSBURGH, Oct. 15 -- About 1% of bariatric surgery patients die within a year of surgery, researchers here found, and the case fatality rate approaches 6% after five years.

But a retrospective look at all of the bariatric surgery performed in Pennsylvania from 1995 through 2004 found a "substantial excess" of deaths by suicide and coronary heart disease, according to Lewis Kuller, M.D., Dr.P.H., of the University of Pittsburgh, and colleagues.

The finding suggests that more intense follow-up -- with an emphasis on signs of depression -- might reduce the long-term death rate associated with such procedures, Dr. Kuller and colleagues reported in the October issue of Archives of Surgery.

Clinicians should also attempt to control risk factors such as hypertension, diabetes mellitus, hyperlipidemia, and smoking, the researchers said.

Combined with other data, however, the findings suggest that bariatric surgery is not overly dangerous, according to Edward Livingston, M.D., of the University of Texas Southwestern Medical Center in Dallas.

Indeed, "it may be a greater hazard to not induce weight loss for morbidly obese patients with concomitant medical complications," Dr. Livingston said in an invited critique of the study.

The data for the study were obtained from the Pennsylvania Health Care Cost and Containment Council and the Division of Vital Records of the state's health department.

Starting with 32 procedures in 1995, 74 hospitals in the state performed steadily increasing numbers, peaking at 4,778 in 2003, before dropping back slightly to 3,818 in 2004.

All told, there have been 440 deaths recorded after 16,683 procedures, the researchers found.

The 30-day case fatality percentage was 0.9% overall. The rate increased with the age of the patient, reaching 3.1% for those 65 and older. There was no evidence that the 30-day fatality rate changed over time.

While 74 hospitals performed bariatric surgery, 90.3% of the procedures took place in just 32 hospitals and 48.2% in only eight, the researchers noted.

Of the 440 deaths, 82.7% took place among the patients of the 32 hospitals that contributed more than 90% of the procedures, Dr. Kuller and colleagues said.

Among the 440 deaths, there were 45 that the researchers defined as traumatic, including 16 due to suicide, 14 due to drug overdoses that were not classified as suicide, 10 due to motor vehicle crashes, three to homicide, and two to falls.

Based on U.S. vital statistics, the researchers estimated that three suicides should have occurred in this population, instead of the 16 that were seen. "There is a substantial excess of suicide deaths, even excluding those listed only as drug overdose," they said.

Among the remaining 395 deaths, the leading cause was coronary heart disease at 19.2%, followed by sepsis at 13.9%, pulmonary embolism at 11.9%, therapeutic complications at 11.4%, and cancer at 10.6%.

In his critique, Dr. Livingston pointed out that "lacking randomized trials, the effect of bariatric surgery on obesity-related mortality is inferential at best."

"What was unexpected," he said, "was the frequency of suicide and drug overdoses."